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 UCLA Policy  136, Attachment  A

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UCLA Mandated Reporter Identification Form

 

Departments must submit this completed form to the appropriate human resources representative on behalf of any UCLA Employee or Official who is a “UCLA Mandated Reporter” (see UCLA Policy 136) and retain a copy in the Employee’s personnel or other appropriate department file. Departments of UCLA Health are exempt from completing this form.

An individual identified, as a UCLA Mandated Reporter shall be given a hardcopy of or web link to UCLA Policy 136 and must sign and return the UCLA Mandated Reporter Acknowledgement Statement (See UCLA Policy 136, Attachment B) to the department, which will forward the signed acknowledgement to the appropriate human resources representative.

UCLA Mandated Reporter’s Name ____________________________ID# __ __ __    __ __ __    __ __ __   

q    UCLA Employee (is any individual who receives compensation through the University’s payroll system or holds a UCLA academic appointment).

q    UCLA Official (referred to as an “administrator” in CANRA) is any individual, other than an Employee, an independent contractor or a volunteer) who supervises University activities, functions or programs).

 

Job Title ________________________________               Supervising Department____________________

 

The individual is a UCLA Mandated Reporter because she or he (check all that apply):

q  is an Employee or Official or other position at UCLA, who by virtue of his or her licensure, has a duty to report under CANRA

q  who within the scope of his or her employment or other position at UCLA, has duties that bring them into direct and regular contact with a child, who is under 18 (but not including faculty or instructors, whose only contact with a child is teaching a class)

q is a researcher whose projects include a child in activities that are on University premises, or at an activity, or program conducted or overseen by the University

q  is a law enforcement or public safety professional, including University police officers and police department Employees and fire marshals

q  is a licensed healthcare professional or resident/trainee/intern who is in training to become a licensed healthcare professional

q is a teacher, aide, counselor, or administrator at K-12 schools, including the UCLA Lab School and Geffen Academy

q is a licensee, contractor, caretaker, or administrator at a preschool, community care, or child day care center, including, but not limited to, the Krieger Center, Fernald Center, University Village Center, Infant Development Program, UCLA Westwood Child Care Center, and University Parents Nursery School

q is an administrator or counselor at a day camp, summer camp, etc. where children attend, reside, or otherwise participate, including the Lake Arrowhead Conference Center & Bruin Woods Family Resort

q is a coach, trainer, managerial or professional staff, or assistant in University-sponsored athletic or recreational activities in which a child participates, including the Department of Intercollegiate Athletics or UCLA Recreation & Campus Life

q is an Employee or Official engaged in theater and film production in which a child participates

q directly supervises UCLA Mandated Reporters

q is an Employee or Official, including faculty, who accompany students, under 18, for educational or travel programs, including study abroad

q  other reason (explain): _____________________________________________________________________________

 

Department head or designee completing this form:

Name of Department head or designee 

 

Job Title

Department

Signature of Department Head or Designee

 

Date

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